Measure #250 (NQF 1853): Radical Prostatectomy Pathology Reporting National Quality Strategy Domain: Effective Clincial Care

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1 Measure #250 (NQF 1853): Radical Prostatectomy Pathology Reporting National Quality Strategy Domain: Effective Clincial Care 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: Percentage of radical prostatectomy pathology reports that include the pt category, the pn category, the Gleason score and a statement about margin status INSTRUCTIONS: This measure is to be reported each time a radical prostatectomy surgical pathology examination is performed during the reporting period for prostate patients. Each unique CPT Category I code or quality-data code submitted on the claim will be counted for denominator inclusion. It is anticipated that clinicians who examine prostate tissue specimens following resection in a laboratory or institution will submit this measure. Independent Laboratories (ILs) and Independent Diagnostic Testing Facilities (IDTFs), using indicator Place of Service 81, are not included in PQRS. If the specimen is not primary prostate tissue (e.g., breast, lung), report only G8798. Measure Reporting via Claims: ICD-10-CM diagnosis codes and CPT codes, are used to identify patients who are included in the measure s denominator. CPT Category II codes or quality-data codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed ICD-10-CM diagnosis codes, CPT codes, and the appropriate CPT Category II code OR quality-data codes OR the CPT Category II code with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measurespecific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: ICD-10-CM diagnosis codes and CPT codes are used to identify patients who are included in the measure s denominator. The listed numerator options are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINATOR: All radical prostatectomy surgical pathology examinations performed during the measurement period for prostate cancer patients Denominator Criteria (Eligible Cases): Diagnosis for malignant neoplasm of prostate (ICD-10-CM): C61 AND Patient encounter during the reporting period (CPT): NUMERATOR: Radical Prostatectomy reports that include the pt category, the pn category, Gleason score and a statement about margin status Numerator Quality-Data Coding Options for Reporting Satisfactorily: Radical Prostatectomy Report includes pt category, pn category, Gleason Score and Statement about Margin Status Performance Met: CPT II 3267F: Pathology report includes pt category, pn category, Gleason score and statement about margin status 11/17/2015 Page 1 of 9

2 OR OR pt category, pn category, Gleason Score and Statement about Margin Status not Documented for Medical Reasons Append a modifier (1P) to Category II code 3267F to report documented circumstances that appropriately exclude patients from the denominator. Medical Performance Exclusion: 3267F with 1P: Documentation of medical reason(s) for not including pt category, pn category, Gleason score and statement about margin status in the pathology report (e.g., specimen originated from other malignant neoplasms, transurethral resections of the prostate (TURP), or secondary site prostatic carcinomas) OR If patient is not eligible for this measure because the specimen is not primary prostate tissue from a radical resection report: Other Performance Exclusion: G8798: Specimen site other than anatomic location of prostate pt category, pn category, Gleason Score and Statement about Margin Status not Documented, Reason not Otherwise Specified Append a reporting modifier (8P) to CPT Category II code 3267F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. Performance Not Met: 3267F with 8P: pt category, pn category, Gleason score and statement about margin status were not documented in pathology report, reason not otherwise specified RATIONALE: Therapeutic decisions for prostate cancer management are stage driven and cannot be made without a complete set of pathology descriptors. Incomplete pathology reports for prostate cancer may result in misclassification of patients, rework and delays, and suboptimal management. The College of American Pathologists Cancer Committee has produced an evidence-based protocol/checklist of essential pathologic parameters that are recommended to be included in prostate cancer resection pathology reports. Conformance of pathology reports with the CAP checklist is a requirement for Cancer Center certification by the ACS. The protocol recommends the use of the TNM Staging System for carcinoma of the prostate of the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC). The radical prostatectomy checklist also includes extraprostatic extension. In a study of cancer recurrence following radical prostatectomy, it was noted that The relatively high proportion of patients who have biopsy-proven local recurrence who have organ-confined disease is probably inaccurate and, in large part, reflects under sampling and under recognition of extraprostatic extension. The CAP Q probes data (2006) indicates that 11.6% of prostate pathology reports had missing elements. Extent of invasion (ptnm) was most frequently missing (52.1% of the reports missing elements), and extraprostatic extension was the second most frequently missing (41.7% of the reports missing elements). Margin status was missing in 8.3% of reports. A sampling from prostate cancer cases in 2000 through 2001 from the College of Surgeons National Cancer Data Base found only 48.2% of surgical pathology reports for prostate cancer documented pathologic stage similar to the more recent data from the CAP Q probes study. The NCDB data showed the Gleason score was present 86.3% of the time, slightly less than the 100% compliance found in the CAP Q probes study and that margin status was present in 84.9% of reports. 11/17/2015 Page 2 of 9

3 CLINICAL RECOMMENDATION STATEMENTS: Patient management and treatment guidelines promote an organized approach to providing quality care. The (American College of Surgeons Committee on Cancer) CoC requires that 90% of pathology reports that include a cancer diagnosis contain the scientifically validated data elements outlined in the surgical case summary checklist of the College of American Pathologists (CAP) publication Reporting on Cancer Specimens. The College regards the reporting elements in the Surgical Pathology Cancer Case Summary (Checklist) portion of the protocols as essential elements of the pathology report. However, the manner in which these elements are reported is at the discretion of each specific pathologist, taking into account clinician preferences, institutional policies, and individual practice. Pathologic staging is usually performed after surgical resection of the primary tumor. Pathologic staging depends on pathologic documentation of the anatomic extent of disease, whether or not the primary tumor has been completely removed. COPYRIGHT: Physician Performance Measures (Measures) and related data specifications developed by the College of American Pathologists are intended to facilitate quality improvement activities by physicians. These Measures are intended to assist physicians in enhancing quality of care. They are designed for use by any physician who manages the care of a patient for a specific condition or for diagnosis or prevention. These Measures are not clinical guidelines and do not establish a standard of medical care. The College has not tested its Measures for all potential applications. Measures are subject to review and may be revised or rescinded at any time by the College. They may not be altered without the prior written approval of the College of American Pathologists. Measures developed by the College of American Pathologists, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use of the Measures is not permitted absent a license agreement between the user and the College of American Pathologists. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. The College of American Pathologists is not responsible for any harm to any party resulting from the use of these Measures. THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND and 2012 College of American Pathologists. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The College of American Pathologists disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. THE SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND and 2012, College of American Pathologists. All rights reserved. CPT contained in the Measures specifications is copyright American Medical Association. 11/17/2015 Page 3 of 9

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6 2016 Claims Individual Measure Flow PQRS #250 NQF #1853: Radical Prostatectomy Pathology Reporting Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure. 1. Start with Denominator 2. Check Patient Diagnosis: a. If Diagnosis of Malignant Neoplasm of Prostate as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Diagnosis of Malignant Neoplasm of Prostate as Listed in the Denominator equals Yes, proceed to check Encounter Performed. 3. Check Encounter Performed: a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Encounter as Listed in the Denominator equals Yes, include in the Eligible population. 4. Denominator Population: a. Denominator population is all Eligible Procedures in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 procedures in the sample calculation. 5. Start Numerator 6. Check Radical Prostatectomy Report includes pt Category, pn Category, Gleason Score and Statement about Margin Status: a. If Radical Prostatectomy Report includes pt Category, pn Category, Gleason Score and Statement about Margin Status equals Yes, include in Reporting Met and Performance Met. b. Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 procedures in Sample Calculation. c. If Radical Prostatectomy Report includes pt Category, pn Category, Gleason Score and Statement about Margin Status equals No, proceed to pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons. 11/17/2015 Page 6 of 9

7 7. Check pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons: a. If pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons equals Yes, include in Reporting Met and Performance Exclusion. b. Reporting Met and Performance Exclusion letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter b1 equals 1 procedure in the Sample Calculation. c. If pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons equals No, proceed to Specimen Site Other than Anatomic Location of Prostate. 8. Check Specimen Site other than Anatomic Location of Prostate: a. If Specimen Site Other than Anatomic Location of Prostate equals Yes, include in Reporting Met and Performance Exclusion. b. Reporting Met and Performance Exclusion letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter b2 equals 0 procedures in the Sample Calculation. c. If Specimen Site Other than Anatomic Location of Prostate equals No, proceed to pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented, Reason Not Specified. 9. Check pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented, Reason Not Specified: a. If pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented, Reason Not Specified equals Yes, include in the Reporting Met and Performance Not Met. b. Reporting Met and Performance Not Met letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter c equals 2 procedures in the Sample Calculation. c. If pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented, Reason Not Specified equals No, proceed to Reporting Not Met. 10. Check Reporting Not Met a. If Reporting Not Met equals No, Quality Data Code or equivalent not reported. 1 procedure has been subtracted from reporting numerator in the sample calculation. 11/17/2015 Page 7 of 9

8 2016 Registry Individual Measure Flow PQRS #250 NQF #1853: Radical Prostatectomy Pathology Reporting Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in reporting this Individual Measure. 1. Start with Denominator 2. Check Patient Diagnosis: a. If Diagnosis of Malignant Neoplasm of Prostate as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Diagnosis of Malignant Neoplasm of Prostate as Listed in the Denominator equals Yes, proceed to check Encounter Performed. 3. Check Encounter Performed: a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Encounter as Listed in the Denominator equals Yes, proceed to Check Specimen Site. 4. Check Specimen Site: a. If Specimen Site Other than Anatomic Location of Prostate equals Yes, do not include in Eligible Patient Population. Stop Processing. b. If Specimen Site Other than Anatomic Location of Prostate equals No, include in the Eligible population. 5. Denominator Population: a. Denominator population is all Eligible Procedures in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 8 procedures in the sample calculation. 6. Start Numerator 7. Check Radical Prostatectomy Report includes pt Category, pn Category, Gleason Score and Statement About Margin Status: a. If Radical Prostatectomy Report includes pt Category, pn Category, Gleason Score and Statement About Margin Status equals Yes, include in Reporting Met and Performance Met. b. Reporting Met and Performance Met letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 4 procedures in Sample Calculation. c. If Radical Prostatectomy Report includes pt Category, pn Category, Gleason Score and Statement About Margin Status equals No, proceed to pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons. 11/17/2015 Page 8 of 9

9 8. Check pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons: a. If pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons equals Yes, include in Reporting Met and Performance Exclusion. b. Reporting Met and Performance Exclusion letter is represented in the Reporting Rate and Performance Rate in the Sample Calculation listed at the end of this document. Letter b equals 1 procedure in the Sample Calculation. c. If pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented for Medical Reasons equals No, proceed to Check pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented, Reason Not Specified. 9. Check pt Category, pn Category, Gleason Score and Statement About Margin Status Not Documented, Reason Not Specified: a. If pt Category, pn Category, Gleason Score and Statement about Margin Status Not Documented, Reason Not Specified equals Yes, include in the Reporting Met and Performance Not Met. b. Reporting Met and Performance Not Met letter is represented in the Reporting Rate in the Sample Calculation listed at the end of this document. Letter c equals 2 procedures in the Sample Calculation. c. If pt Category, pn Category, Gleason Score and Statement about Margin Status Not Documented, Reason Not Specified equals No, proceed to Reporting Not Met. 10. Check Reporting Not Met a. If Reporting Not Met equals No, Quality Data Code or equivalent not reported. 1 procedure has been subtracted from reporting numerator in the sample calculation. 11/17/2015 Page 9 of 9

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